ATI RN
test bank for health assessment Questions
Question 1 of 5
What should the nurse do first when caring for a client with chest pain?
Correct Answer: A
Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.
Question 2 of 5
What is the priority nursing action for a client who is receiving blood transfusion and develops a fever?
Correct Answer: A
Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.
Question 3 of 5
Which sign might a nurse observe in a client with a high ammonia level?
Correct Answer: A
Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.
Question 4 of 5
What should the nurse do first for a client who is post-operative and experiences confusion?
Correct Answer: A
Rationale: The correct answer is A: Reorient the client. This is the first step because confusion post-operatively could be due to anesthesia, pain medications, or disorientation. Reorienting the client helps bring them back to reality and decrease anxiety. B: Monitoring for signs of infection would be important but not the initial step for confusion. C: Monitoring serum electrolytes is important but not the immediate priority for confusion. D: Applying a cold compress is not relevant for confusion in a post-operative client.
Question 5 of 5
What is the priority action when caring for a client with a severe burn?
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.